|
City of Orono &03C
<br /> Building Permit Application for Maintenance / Replacement / Renovation
<br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.)
<br /> t o A PO Box 66 Mailing Address. Permit number:
<br /> Crystal Bay, MN 55323-0066 Date received:
<br /> Street Address: Received by.
<br /> y 2750 Kelley Parkway Plan review fee:
<br /> W Orono, MN 55356
<br /> kE S H O L/5. • 2"CTotal Fee:
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
<br /> This application form must be completed in full and all required information must be submitted.
<br /> Incomplete applications will be returned. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: ( 5 c'T---- Ure-OAC) OP,(e-S I/2 (L,,,\_,
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No
<br /> If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus ice will be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR I APPLICANT INFORMATION:
<br /> Name. .$ , '<'0 •, R s•►.' Fc—DSS C)„1—cQ 1/4_,l''2_ e.-L-(:-
<br /> State
<br /> .-L,c-State License # •-p,.,✓ 3 8 O ff.-2--- Expiration Date: .�-3 / .1/<t-
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell) CP(Z_-L2ca_ `3(n (cl (office)
<br /> Mailing Address: c SA^., ,, C_.' ,(,,� City: 4c.o,AJ;/I ZIP: 5-S-38--)
<br /> Contact Person: (7_64,AyL__ <,c-; Applicant i . Contractor / Homeowner (Circle One)
<br /> Email and/or Fax: j- g -z,c.t2,_�(4„,r,`
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: -Si M (-(-t inln)iNE,c -n_
<br /> Phone (day): Cit -;-'-_,- 417ca -. d;o-77
<br /> Address: ( -3;- 0r,arvv Dille_ 1.--)R-L,ic-k-. City: OR-o1•1 ZIP: ICS-35 ,-9' O
<br /> Email and/or Fax: _�
<br /> PROJECT INFORMATION: Overall project description:
<br /> Type of Project: Any earth movement may also require
<br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits:
<br /> Sze-roof, asphalt Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD)
<br /> 18202 Minnetonka Blvd
<br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391
<br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> ❑Window(s) www.minnehahacreek.orq
<br /> Estimated Construction Valuation of Project (excluding land) $ 2_ ', 000—
<br /> APPLICANT ACKNOWLEDGEMENT: ��� 1,---- ) CAP-F:61- (}( ,
<br /> -ri0..� .� --P<,,
<br /> • Agrees to provide all information required or requested by the Building Department; _T
<br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are
<br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to
<br /> reject it until it is complete;
<br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or
<br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data.
<br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and
<br /> intended use of this informal n-is to annually update our records and records of other governmental agencies required by law. If
<br /> you refuse to supply the ' orma(yon,the application may not be issued.
<br /> Applicant's Signature: _ Date: cy- c>/-.3
<br /> Owner's Signature: Date:
<br /> Last Updated: 03/06/2013
<br />
|